Susan M. Frayne, MD, MPH

Abstract

While prior research characterizes women Veterans' barriers to accessing and using Veterans Health Administration (VA) care, there has been little attention to women who access VA and use services, but then discontinue use. Recent data suggest that among women Veterans, there is a 30 % attrition rate within 3 years of initial VA use.To compare individual characteristics and perceptions about VA care between women Veteran VA attriters (those who discontinue use) and non-attriters (those who continue use), and to compare recent versus remote attriters.Cross-sectional, population-based 2008-2009 national telephone survey.Six hundred twenty-six attriters and 2,065 non-attriters who responded to the National Survey of Women Veterans.Population weighted demographic, military and health characteristics; perceptions about VA healthcare; length of time since last VA use; among attriters, reasons for no longer using VA care.Fifty-four percent of the weighted VA ever user population reported that they no longer use VA. Forty-five percent of attrition was within the past ten years. Attriters had better overall health (p = 0.007), higher income (p < 0.001), and were more likely to have health insurance (p < 0.001) compared with non-attriters. Attriters had less positive perceptions of VA than non-attriters, with attriters having lower ratings of VA quality and of gender-specific features of VA care (p < 0.001). Women Veterans who discontinued VA use since 2001 did not differ from those with more remote VA use on most measures of VA perceptions. Overall, among attriters, distance to VA sites of care and having alternate insurance coverage were the most common reasons for discontinuing VA use.We found high VA attrition despite recent advances in VA care for women Veterans. Women's attrition from VA could reduce the critical mass of women Veterans in VA and affect current system-wide efforts to provide high-quality care for women Veterans. An understanding of reasons for attrition can inform organizational efforts to re-engage women who have attrited, to retain current users, and potentially to attract new VA patients.

View details for DOI 10.1007/s11606-013-2347-y

View details for Web of Science ID 000321910900006

View details for PubMedID 23807058

Abstract

We evaluated receipt of cervical cancer screening in a national sample of 34,213 women veterans using Veteran Health Administration facilities between 2003 and 2007 and diagnosed with 1) posttraumatic stress disorder (PTSD), or 2) depression, or 3) no psychiatric illness.Our study featured a cross-sectional design in which logistic regression analyses compared receipt of recommended cervical cancer screening for all three diagnostic groups.Cervical cancer screening rates varied minimally by diagnostic group: 77% of women with PTSD versus 75% with depression versus 75% without psychiatric illness were screened during the study observation period (p < .001). However, primary care use was associated with differential odds of screening in women with versus without psychiatric illness (PTSD or depression), even after adjustment for age, income and physical comorbidities (Wald Chi-square (2): 126.59; p < .0001). Specifically, among low users of primary care services, women with PTSD or depression were more likely than those with no psychiatric diagnoses to receive screening. Among high users of primary care services, they were less likely to receive screening.Psychiatric illness (PTSD or depression) had little to no effect on receipt of cervical cancer screening. Our finding that high use of primary care services was not associated with comparable odds of screening in women with versus without psychiatric illness suggests that providers caring for women with PTSD or depression and high use of primary care services should be especially attentive to their preventive healthcare needs.

View details for DOI 10.1016/j.whi.2013.03.002

View details for PubMedID 23660429

Abstract

This study sought to examine whether a web-delivered brief alcohol intervention (BAI) is effective for reducing alcohol misuse in U.S. military veterans presenting to primary care.Veterans (N = 167) screening positive for alcohol misuse during a routine primary care visit were randomized to receive a BAI plus treatment as usual (TAU) or TAU alone. An assessment of alcohol-related outcomes was conducted at baseline and 3 and 6 months after treatment.Veterans in both study conditions showed a significant reduction in alcohol quantity and frequency and alcohol-related problems at 6-month follow-up. No differential treatment effects on outcomes were observed between the two treatment groups.This study is the first to explore whether a web-delivered BAI using normative feedback is effective for veterans with alcohol misuse. Our findings suggest that BAIs using normative feedback may not have any additional benefit beyond TAU for older veterans with high rates of comorbid mental health concerns.

View details for Web of Science ID 000316644300009

View details for PubMedID 23490572

Abstract

Atrial fibrillation and flutter (AF, collectively) cause stroke. We evaluated whether treating specialty influences warfarin prescription in patients with newly diagnosed AF.In the TREAT-AF study, we used Veterans Health Administration health record and claims data to identify patients with newly diagnosed AF between October 2004 and November 2008 and at least 1 internal medicine/primary care or cardiology outpatient encounter within 90 days after diagnosis. The primary outcome was prescription of warfarin.In 141,642 patients meeting the inclusion criteria, the mean age was 72.3 ± 10.2 years, 1.48% were women, and 25.8% had cardiology outpatient care. Cardiology-treated patients had more comorbidities and higher mean CHADS2 scores (1.8 vs 1.6, P < .0001). Warfarin use was higher in cardiology-treated vs primary care only-treated patients (68.6% vs 48.9%, P < .0001). After covariate and site-level adjustment, cardiology care was significantly associated with warfarin use (odds ratio [OR] 2.05, 95% CI 1.99-2.11). These findings were consistent across a series of adjusted models (OR 2.05-2.20), propensity matching (OR 1.98), and subgroup analyses (OR 1.58-2.11). Warfarin use in primary-care-only patients declined from 2004 to 2008 (51.6%-44.0%, P < .0001), whereas the adjusted odds of warfarin receipt with cardiology care (vs primary care) increased from 2004 to 2008 (1.88-2.24, P < .0001).In patients with newly diagnosed AF, we found large differences in anticoagulation use by treating specialty. A divergent 5-year trend of risk-adjusted warfarin use was observed. Treating specialty influences stroke prevention care and may impact clinical outcomes.

View details for DOI 10.1016/j.ahj.2012.10.010

View details for Web of Science ID 000312272900017

View details for PubMedID 23237139

Abstract

We examined rates of specific health conditions among female veteran patients and how the share of health care costs attributable to these conditions changed in the Veterans Affairs system between 2000 and 2008.Veterans' Administration (VA)-provided and VA-sponsored inpatient, outpatient, and pharmacy utilization and cost files were analyzed for women veterans receiving care in 2000 and 2008. We estimated rates of 42 common health conditions and per-patient condition costs from a regression model and calculated the total population costs attributable to each condition and changes by year.The number of female VA patients increased from 156,305 in 2000 to 266,978 in 2008; 88% were under 65 years of age. The rate of women treated for specific conditions increased substantially for many gender-specific and psychiatric conditions: For example, pregnancy increased 133%, diagnosed posttraumatic stress disorder increased 106%, and diagnosed depression increased 41%. Mean costs of care increased from $4,962 per woman in 2000 to $6,570 per woman in 2008. Psychiatric conditions accounted for more than one quarter of population health care costs in 2008. Gender-specific conditions and musculoskeletal diseases accounted for a rising share of population costs and rose to 8.2% and 8.7% of population costs in 2008, respectively.Gender-specific, cancer, musculoskeletal, and mental health and substance use disorders accounted for a greater share of overall costs during the study period and were primarily driven by higher rates of diagnosed conditions and, for several conditions, higher treatment costs.

View details for DOI 10.1016/j.whi.2012.03.002

View details for PubMedID 22555220

Abstract

Evidence suggests that posttraumatic stress disorder (PTSD) and substance use disorders (SUD) are associated with poorer physical health among U.S. veterans who served in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF). No research of which we are aware has examined the independent and interactive effects of PTSD and SUD on medical comorbidity among OEF/OIF veterans. This cross-sectional study examined medical record data of female and male OEF/OIF veterans with ? 2 Veterans Affairs primary care visits (N = 73,720). Gender-stratified logistic regression analyses, adjusted for sociodemographic factors, were used to examine the association of PTSD, SUD, and their interaction on the odds of medical diagnoses. PTSD was associated with increased odds of medical diagnoses in 9 of the 11 medical categories among both women and men, range of odds ratios (ORs) ranged from 1.07 to 2.29. Substance use disorders were associated with increased odds of 2 of the 11 medical categories among women and 3 of the 11 medical categories among men; ORs ranged from 1.20 to 1.74. No significant interactions between PTSD and SUD were detected for women or men. Overall, findings suggest that PTSD had a stronger association with medical comorbidity (in total and across various medical condition categories) than SUD among female and male OEF/OIF veterans.

View details for DOI 10.1002/jts.21690

View details for Web of Science ID 000303041500016

View details for PubMedID 22522739

Abstract

This exploratory study investigated organizational factors associated with receipt of military sexual trauma (MST) screening during an early timeframe of the Veterans Health Administration's (VHA) implementation of the universal MST screening policy.The sample consisted of all VHA patients eligible for MST screening in fiscal year 2005 at 119 VHA facilities. Analyses were conducted separately by gender and by user status (i.e., new patients to the VHA health care system in FY 2005 and continuing users who had previously used the VHA health care system in the past year). Multivariate generalized estimating equations were used to assess the effects of facility-level characteristics and adjusted for person-level covariates.Facility-level mandatory universal MST screening policies were associated with increased odds of receiving MST screening among new female patients and both continuing and new male patients: Odds ratio (OR), 2.87 (95% confidence interval [CI], 1.39-5.89) for new female patients; OR, 8.15 (95% CI, 2.93-22.69) for continuing male patients; and OR, 4.48 (95% CI, 1.79-11.20) for new male patients. Facility-level audit and feedback practices was associated with increased odds of receiving MST screening among new patients: OR, 1.91 (95% CI, 1.26-2.91) for females and OR, 1.86 (95% CI, 1.22-2.84) for males. Although the facility-level effect for women's health clinic (WHC) did not emerge as significant, patient-level effects indicated that among these facilities, women who used a WHC had greater odds of being screened for MST compared with women who had not used a WHC: OR, 1.79 (95% CI, 1.18-2.71) for continuing patients and OR, 2.20 (95% CI, 1.59-3.04) for new patients.This study showed that facility policies that promote universal MST screening, as well as audit and feedback practices at the facility, significantly improved the odds of patients receiving MST screening. Women veterans' utilization of a WHC was associated with higher odds of receiving MST screening. This study provides empirical support for the use of policies and audit and feedback practices which the VHA has used since the implementation of the MST screening directive to encourage compliance with VHA's MST screening policy and is likely associated with the present-day success in MST screening across all VHA facilities.

View details for DOI 10.1016/j.whi.2011.09.001

View details for PubMedID 22055987

Abstract

Spinal cord injury (SCI) care is a high priority for the Veterans Health Administration (VHA). Aging Veterans, new cases of SCI from recent conflicts, and increasing numbers of women Veterans have likely changed the profile of the VHA SCI population. This study characterizes the current Veteran population with SCI with emphasis on healthcare utilization and women Veterans. We analyzed VHA administrative data from 2002-2003 and 2007-2008, analyzing composition, demographics, and healthcare use. The population is mostly male (>97%) and largely between 45 and 64 years old. Over 30% are over the age of 65. They are frequent users of healthcare, with an average of 21 visits per year. Women Veterans with SCI form a small but distinct subpopulation, being younger and less likely to be married and having a higher burden of disease. We must understand how the VHA population with SCI is changing to anticipate and provide the best care for these complex patients.

View details for PubMedID 22773195

Abstract

To determine whether atrial fibrillation (AF) patients with mental health conditions (MHCs) were less likely than AF patients without MHCs to be prescribed warfarin and, if receiving warfarin, to maintain an International Normalized Ratio (INR) within the therapeutic range.Detailed chart review of AF patients using a Veterans Health Administration (VHA) facility in 2003.For a random sample of 296 AF patients, records identified clinician-diagnosed MHCs (independent variable) and AF-related care in 2003 (dependent variables), receipt of warfarin, INR values below/above key thresholds, and time spent within the therapeutic range (2.0-3.0) or highly out of range. Differences between the MHC and comparison groups were examined using X2 tests and logistic regression controlling for age and comorbidity.Among warfarin-eligible AF patients (n = 246), 48.5% of those with MHCs versus 28.9% of those without MHCs were not treated with warfarin (P = .004). Among those receiving warfarin and monitored in VHA, highly supratherapeutic INRs were more common in the MHC group; for example, 27.3% versus 1.6% had any INR >5.0 (P <.001). Differences persisted after adjusting for age and comorbidity.MHC patients with AF were less likely than those without MHC to have adequate management of their AF care. Interventions directed at AF patients with MHC may help to optimize their outcomes.

View details for Web of Science ID 000295129700008

View details for PubMedID 21902447

Abstract

Many studies have documented the link between substance use and a history of sexual assault in women; however, few studies have examined this relationship in men. The purpose of this study was to explore the rates of sexual assault in a sample of male veterans reporting alcohol misuse and to further explore potential differences in alcohol use patterns and alcohol-related characteristics in those with and without a history of sexual assault. We also explored the types of illicit drugs being used in the past 90 days and whether a clinical sample of male veterans reporting sexual assault are at greater odds of using these substances when compared with their peers with no history of sexual assault.Data were collected on a nationwide sample (N = 880) of male veterans receiving care in Veterans Administration outpatient mental health clinics.We found that 9.5% of our sample reported a history of sexual assault, and those with this history reported increased alcohol consumption, a greater number of alcohol-related consequences, and an increased likelihood of using an illicit substance in the past 90 days. The most commonly used illicit substances were cannabis, cocaine, and opiates. Those with sexual assault histories were also more likely to report risk factors that may exacerbate the negative effects of any level of alcohol consumption.Our findings highlight the burden of alcohol and illicit drug use among male veterans and suggest that substance use disorder treatment settings may be a context in which prevalence of a history of sexual assault is high. Our findings further support prior call for universal screening for sexual assault among this population.

View details for Web of Science ID 000295562500001

View details for PubMedID 21906496

Abstract

The purpose of this paper is to report on the outcomes of the 2010 VA Women's Health Services Research Conference, which brought together investigators interested in pursuing research on women veterans and women in the military with leaders in women's health care delivery and policy within and outside the VA, to significantly advance the state and future direction of VA women's health research and its potential impacts on practice and policy. Building on priorities assembled in the previous VA research agenda (2004) and the research conducted in the intervening six years, we used an array of approaches to foster research-clinical partnerships that integrated the state-of-the-science with the informational and strategic needs of senior policy and practice leaders. With demonstrated leadership commitment and support, broad field-based participation, strong interagency collaboration and a push to accelerate the move from observational to interventional and implementation research, the Conference provided a vital venue for establishing the foundation for a new research agenda. In this paper, we provide the historical evolution of the emergence of women veterans' health services research and an overview of the research in the intervening years since the first VA women's health research agenda. We then present the resulting VA Women's Health Research Agenda priorities and supporting activities designed to transform care for women veterans in six broad areas of study, including access to care and rural health; primary care and prevention; mental health; post deployment health; complex chronic conditions, aging and long-term care; and reproductive health.

View details for DOI 10.1016/j.whi.2011.04.002

View details for Web of Science ID 000292785100005

View details for PubMedID 21724148

Abstract

The number of women veterans using Veterans Health Administration (VHA) services has increased rapidly, but the characteristics of women joining VHA are not well understood. We sought to describe sociodemographic characteristics, utilization, and retention of new and returning women VHA patients over a 7-year period.We identified women veterans who used VHA outpatient services from VHA Enrollment and Utilization files for fiscal years 2003 through 2009. "New" patients in a given year had no outpatient use within the prior 3 years. Patients were "retained" if they continued to use VHA in subsequent years.Of the 287,447 women veteran VHA outpatients in 2009, 40,000 (14%) were new to VHA in that year and over half had joined VHA since 2003. Nearly two thirds of these new patients were younger than 45, and 43% carried a service-connected disability status. Most new patients (88%) received primary care services in 2008, and 40% used mental health services. Repeated use of mental health services (at least three visits per year) nearly doubled among new patients (from 11% in 2003 to 20% in 2008). Among those using VHA primary care in 2006, 68% of new patients versus 91% of returning patients were retained in either of the subsequent 2 years.The influx of new women veterans seeking VHA services in recent years, combined with their high rate of retention within VHA, contribute to the marked increase in numbers of women veterans using VHA. Many require fairly intensive VHA services.

View details for DOI 10.1016/j.whi.2011.04.025

View details for Web of Science ID 000292785100008

View details for PubMedID 21724129

View details for DOI 10.1016/j.whi.2011.04.030

View details for Web of Science ID 000292785100002

View details for PubMedID 21724145

Abstract

There has been considerable focus on the burden of mental illness (including post-traumatic stress disorder, PTSD) in returning Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans, but little attention to the burden of medical illness in those with PTSD.(1) Determine whether the burden of medical illness is higher in women and men OEF/OIF veterans with PTSD than in those with No Mental Health Conditions (MHC). (2) Identify conditions common in those with PTSD.Cross-sectional study using existing databases (Fiscal Year 2006-2007).Veterans Health Administration (VHA) patients nationally.All 90,558 OEF/OIF veterans using VHA outpatient care nationally, categorized into strata: PTSD, Stress-Related Disorders, Other MHCs, and No MHC.(1) Count of medical conditions; (2) specific medical conditions (from ICD9 codes, using Agency for Health Research and Quality's Clinical Classifications software framework).The median number of medical conditions for women was 7.0 versus 4.5 for those with PTSD versus No MHC (p<0.001), and for men was 5.0 versus 4.0 (p<0.001). For PTSD patients, the most frequent conditions among women were lumbosacral spine disorders, headache, and lower extremity joint disorders, and among men were lumbosacral spine disorders, lower extremity joint disorders, and hearing problems. These high frequency conditions were more common in those with PTSD than in those with No MHC.Burden of medical illness is greater in women and men OEF/OIF veteran VHA users with PTSD than in those with No MHC. Health delivery systems serving them should align clinical program development with their medical care needs.

View details for DOI 10.1007/s11606-010-1497-4

View details for Web of Science ID 000286338900014

View details for PubMedID 20853066

Abstract

The study aimed to examine treatment patterns for depression among women veterans diagnosed with cardiovascular conditions or diabetes. We used longitudinal data from the 2002-2003 merged Veteran Health Administration (VHA) and Medicare files. Chi-square tests and multinomial logistic regression were performed to analyse depression treatment among veteran women with incident depressive episode and one of the following chronic conditions: diabetes or coronary artery disease or hypertension. Overall, 77% received treatment for depression, 54% with only antidepressants, 4% with only psychotherapy, and 19% with both. Multinomial logistic regression revealed that African American women were more likely to be in the no treatment group and were more likely than white women to receive psychotherapy rather than antidepressants. Older women and women with coronary artery disease only were less likely to receive treatment.

View details for Web of Science ID 000282859200012

View details for PubMedID 20975865

Abstract

We examined military-related sexual trauma among deployed Operation Enduring Freedom and Operation Iraqi Freedom veterans. Of 125 729 veterans who received Veterans Health Administration primary care or mental health services, 15.1% of the women and 0.7% of the men reported military sexual trauma when screened. Military sexual trauma was associated with increased odds of a mental disorder diagnosis, including posttraumatic stress disorder, other anxiety disorders, depression, and substance use disorders. Sexual trauma is an important postdeployment mental health issue in this population.

View details for DOI 10.2105/AJPH.2009.171793

View details for Web of Science ID 000282354800015

View details for PubMedID 20558808

Abstract

Sexual violence and posttraumatic stress disorder (PTSD) have been linked to increased reports of distress and pain during the pelvic examination. Efforts to more fully characterize these reactions and identify core factors (i.e., beliefs about the examination) that may influence these reactions are warranted.This descriptive, cross-sectional study examines the relationship between sexual violence, PTSD, and women's negative reactions to the pelvic examination. Additional analyses highlight how maladaptive beliefs about the safety, necessity, and utility of the pelvic examination may contribute to these reactions. Materials andA total of 165 eligible women veterans were identified via medical record review and mailed a survey that assessed: (1) background information; (2) history of sexual violence; (3) current symptoms of posttraumatic stress disorder; (4) fear, embarrassment, distress, and pain during the pelvic examination; and (5) core beliefs about the examination. Ninety women (55% response rate) completed the survey.Women with both sexual violence and PTSD reported the highest levels of examination related fear: chi(2) = 18.8, p < .001; embarrassment: chi(2) = 21.2, p < .001; and distress: chi(2) = 18.2, p < .001. Beliefs that the examination was unnecessary or unsafe or not useful were more commonly reported in this group and were associated with higher levels of examination-related fear and embarrassment.Women with sexual violence and PTSD find the pelvic examination distressing, embarrassing, and frightening. Efforts to develop interventions to help reduce distress during the examination are warranted.

View details for DOI 10.1089/jwh.2009.1673

View details for Web of Science ID 000279428800007

View details for PubMedID 20509787

Abstract

The authors estimated the validity of algorithms for identification of mental health conditions (MHCs) in administrative data for the 133 068 diabetic patients who used Veterans Health Administration (VHA) nationally in 1998 and responded to the 1999 Large Health Survey of Veteran Enrollees. They compared various algorithms for identification of MHCs from International Classification of Diseases, 9th Revision (ICD-9) codes with self-reported depression, posttraumatic stress disorder, or schizophrenia from the survey. Positive predictive value (PPV) and negative predictive value (NPV) for identification of MHC varied by algorithm (0.65-0.86, 0.68-0.77, respectively). PPV was optimized by requiring > or =2 instances of MHC ICD-9 codes or by only accepting codes from mental health visits. NPV was optimized by supplementing VHA data with Medicare data. Findings inform efforts to identify MHC in quality improvement programs that assess health care disparities. When using administrative data in mental health studies, researchers should consider the nature of their research question in choosing algorithms for MHC identification.

View details for DOI 10.1177/1062860609346347

View details for Web of Science ID 000273214000005

View details for PubMedID 19855046

Abstract

Methodological challenges arise when one uses various Veterans Health Administration (VHA) data sources, each created for distinct purposes, to characterize length of stay (LOS). To illustrate this issue, we examined how algorithm choice affects conclusions about mental health condition (MHC)-related differences in LOS for VHA patients with diabetes nationally (n = 784,321). We assembled a record-level database of all fiscal year (FY) 2003 inpatient care. In 10 steps, we sequentially added instances of inpatient care from various VHA sources. We processed databases in three stages, truncating stays at the beginning and end of FY03 and consolidating overlapping stays. For patients with MHCs versus those without MHCs, mean LOS was 17.7 versus 13.6 days, respectively (p < 0.001), for the crudest algorithm and 37.2 versus 21.7 days, respectively (p < 0.001), for the most refined algorithm. Researchers can improve the quality of data applied to VHA systems redesign by applying methodological considerations raised by this study to inform LOS algorithm choice.

View details for DOI 10.1682/JRRD.2009.08.0112

View details for Web of Science ID 000285074300006

View details for PubMedID 21110246

Abstract

To examine whether veterans who received chronic opioid therapy had worse diabetes performance measures than patients who did not receive opioids.Retrospective cohort study.We identified all patients with diabetes mellitus receiving care in US Department of Veterans Affairs facilities during 2004. Cases received at least 6 prescriptions for chronic opioids during 2004, while controls were randomly selected from among patients with diabetes who received no opioids. We compared process measures (glycosylated hemoglobin and low-density lipoprotein cholesterol levels tested and an eye examination performed) and outcome measures (glycosylated hemoglobin level < or =9.0% and low-density lipoprotein cholesterol level < or =130 mg/dL) between groups.Cases (n = 47,756) had slightly worse diabetes performance measures than controls (n = 220,912) after adjustment for covariates. For example, 86.4% of cases and 89.0% of controls had a glycosylated hemoglobin test during fiscal year 2004 (adjusted odds ratio, 0.69; P <.001). Among cases, receipt of higher-dose opioids was associated with additional decrement in diabetes performance measures, with a dose-response relationship.Chronic opioid therapy among patients within the Veterans Affairs system is associated with slightly worse diabetes performance measures compared with patients who do not receive opioids. However, patients receiving higher dosages of opioids had additional decrements in diabetes performance measures; these patients may be appropriate targets for interventions to improve their care for pain and diabetes.

View details for Web of Science ID 000265237100002

View details for PubMedID 19355794

Abstract

Oral anticoagulation with warfarin is an increasingly common medical intervention. Despite its efficacy, warfarin is difficult to manage, contributing to potential for patient harm. Efforts to measure the quality of oral anticoagulation care have focused disproportionately on the identification of ideal candidates for warfarin therapy, with comparatively little effort in measuring the quality of oral anticoagulation care once therapy has begun. To address this gap in the literature, a MEDLINE search was conducted for all papers relevant to possible quality measures in oral anticoagulation care, including measures of structure, process, and outcomes of care. LIMITATIONS, CONCERNS, AND CHALLENGES OF QUALITY MEASUREMENT IN ORAL ANTICOAGULATION: Because they do not have intrinsic significance, measures of structure and process should be strongly related to outcomes that matter to merit our interest. Consensus guidelines may provide useful guidance to practicing clinicians but may not represent valid process measures. Outcome measures must be studied with databases that provide sufficient statistical power to reliably demonstrate real differences between providers or sites of care.Oral anticoagulation care, a common and serious condition, is in need of a program of quality measurement. This article suggests a research agenda to begin such a program. Previous research has established the evidence for anticoagulant therapy across a broad spectrum of indications and has helped to achieve consensus on the optimal target intensity for various indications. The next task will be to use this body of evidence to develop valid measures of the structure, process, and outcomes of oral anticoagulation care. Quality indicators provide a framework for quality improvement, two goals of which are to maximize the effectiveness of therapy and to minimize harm.

View details for PubMedID 19326806

Abstract

To estimate the range and severity of distress and pain during pelvic examinations among female veterans with and without histories of sexual violence, and to examine whether posttraumatic stress disorder explains additional variance in examination-related distress and pain above that accounted for by exposure to sexual violence.We employed a cross-sectional cohort design in which 67 selected female veterans completed self-administered questionnaires to assess history of sexual violence and experiences of distress and pain associated with the pelvic examination. A subsample of 49 completed an assessment for posttraumatic stress disorder approximately 2 weeks later.Distress associated with the pelvic examination was highest for women with prior sexual violence and posttraumatic stress disorder (median 5.49), next highest for women with sexual violence only (median 2.44), and lowest for women with neither (median 0), P=.015. Higher ratings of pain were also found among women with sexual violence (median 2.5) compared with those without (median 0), P=.04. However, posttraumatic stress disorder was not linked with increased pain from speculum insertion beyond that accounted for by sexual violence; limited power may have precluded detection of this effect.Distress and pain during pelvic examinations may indicate a history of previous sexual violence, particularly in those with posttraumatic stress disorder. Extra sensitivity to the special needs of this population is warranted and may contribute positively to the quality of patients' experiences.II.

View details for Web of Science ID 000261316200022

View details for PubMedID 19037045

Abstract

Despite an association between violence perpetration and substance use, the characteristics associated with violence among patients in treatment for substance use disorders (SUDs) are not well documented. Data were gathered from a national sample of men (n = 4,459) and women (n = 1,774) entering SUD treatment on history of violence perpetration, exposure to childhood physical abuse (CPA) and childhood sexual abuse (CSA), and reasons for entering treatment. Rates of violence perpetration were high (72% of men, 50% of women), and violence was associated with being referred by family members, prior SUD treatment, CPA, and CSA. In multivariate analyses, CPA was a significant correlate of violence perpetration across gender; however, CSA was only significant among women. Findings highlight the need for increased screening and treatment of violence perpetration among patients with SUD and suggest that CSA may be an important correlate of violence perpetration among women.

View details for DOI 10.1016/j.jsat.2007.10.002

View details for Web of Science ID 000258799100013

View details for PubMedID 18248945

Abstract

In an effort to assess and reduce gender-related quality gaps, the Veterans Health Administration (VHA) has promoted gender-based research. Historically, such appraisals have often relied on secondary databases, with little attention to methodological implications of the fact that VHA provides care to some nonveteran patients.To determine whether conclusions about gender differences in utilization and cost of VHA care change after accounting for veteran status.Cross-sectional.All users of VHA in 2002 (N = 4,429,414).Veteran status, outpatient/inpatient utilization and cost, from centralized 2002 administrative files.Nonveterans accounted for 50.7% of women (the majority employees) but only 3.0% of men. Among all users, outpatient and inpatient utilization and cost were far lower in women than in men, but in the veteran subgroup these differences decreased substantially or, in the case of use and cost of outpatient care, reversed. Utilization and cost were very low among women employees; women spouses of fully disabled veterans had utilization and costs similar to those of women veterans.By gender, nonveterans represent a higher proportion of women than of men in VHA, and some large nonveteran groups have low utilization and costs; therefore, conclusions about gender disparities change substantially when veteran status is taken into account. Researchers seeking to characterize gender disparities in VHA care should address this methodological issue, to minimize risk of underestimating health care needs of women veterans and other women eligible for primary care services.

View details for Web of Science ID 000255452100014

View details for PubMedID 18438204

Abstract

Studies of prostitution have focused largely on individuals involved in the commercial sex trade, with an emphasis on understanding the public health effect of this behavior. However, a broader understanding of how prostitution affects mental and physical health is needed. In particular, the study of prostitution among individuals in substance use treatment would improve efforts to provide comprehensive treatment.To document the prevalence of prostitution among women and men entering substance use treatment, and to test the association between prostitution, physical and mental health, and health care utilization while adjusting for reported history of childhood sexual abuse, a known correlate of prostitution and poor health outcomes.Cross-sectional, secondary data analysis of 1606 women and 3001 men entering substance use treatment in the United States who completed a semistructured intake interview as part of a larger study.Self-reported physical health (respiratory, circulatory, neurological, and internal organ conditions, bloodborne infections) and mental health (depression, anxiety, psychotic symptoms, and suicidal behavior), and use of emergency department, clinic, hospital, or inpatient mental health services within the past year.Many participants reported prostitution in their lifetime (50.8% of women and 18.5% of men) and in the past year (41.4% of women and 11.2% of men). Prostitution was associated with increased risk for bloodborne viral infections, sexually transmitted diseases, and mental health symptoms. Prostitution was associated with use of emergency care in women and use of inpatient mental health services for men.Prostitution was common among a sample of individuals entering substance use treatment in the United States and was associated with higher risk of physical and mental health problems. Increased efforts toward understanding prostitution among patients in substance use treatment are warranted. Screening for prostitution in substance use treatment could allow for more comprehensive care to this population.

View details for Web of Science ID 000253672200011

View details for PubMedID 18316680

Abstract

The healthcare needs of lesbians are not well understood. We sought to characterize lesbians' experiences with, and preferences for, women's healthcare.We conducted three age-stratified focus groups (18-29, 30-50, and >50 years) with a total of 22 participants using a semistructured interview guide to elicit lesbians' experiences and preferences. We analyzed transcripts of these audiotaped sessions using the constant comparative method of grounded theory. Community-dwelling women who self-identified as lesbian and responded to advertisements were selected on first-come basis.Participants voiced experiences and preferences for healthcare that emerged into three themes: desired models of care, desired processes of care, and desired patient-provider relationship. Each theme was further developed into multiple subthemes. Within the subthemes we identified issues that were specific to lesbians and those that were general women's health issues. Participants preferred, but did not always receive, care that is comprehensive in scope, person centered, nondiscriminatory, and inclusive of them as lesbians.Healthcare providers, institutions, and society should adopt an inviting, person-centered approach toward lesbians seeking healthcare, assure them access to healthcare information, and establish healthcare delivery systems that take all aspects of health into account.

View details for DOI 10.1089/jwh.2007.0083

View details for Web of Science ID 000254734700006

View details for PubMedID 18321173

Abstract

We examined the utility of the Veterans Health Administration (VHA) universal screening program for military sexual violence.We analyzed VHA administrative data for 185,880 women and 4139888 men who were veteran outpatients and were treated in VHA health care settings nationwide during 2003.Screening was completed for 70% of patients. Positive screens were associated with greater odds of virtually all categories of mental health comorbidities, including posttraumatic stress disorder (adjusted odds ratio [AOR]=8.83; 99% confidence interval [CI] = 8.34, 9.35 for women; AOR = 3.00; 99% CI = 2.89, 3.12 for men). Associations with medical comorbidities (e.g., chronic pulmonary disease, liver disease, and for women, weight conditions) were also observed. Significant gender differences emerged.The VHA policies regarding military sexual trauma represent a uniquely comprehensive health care response to sexual trauma. Results attest to the feasibility of universal screening, which yields clinically significant information with particular relevance to mental health and behavioral health treatment. Women's health literature regarding sexual trauma will be particularly important to inform health care services for both male and female veterans.

View details for DOI 10.2105/AJPH.2006.092999

View details for Web of Science ID 000251395900020

View details for PubMedID 17971558

Abstract

Historically, men have been the predominant users of Veterans Health Administration (VHA) care. With more women entering the system, a systematic assessment of their healthcare use and costs of care is needed. We examined how utilization and costs of VHA care differ in women veterans compared with men veterans.In this cross-sectional study using centralized VHA administrative databases, main analyses examined annual outpatient and inpatient utilization and costs of care (outpatient, inpatient, and pharmacy) for all female (n = 178,849) and male (n = 3,943,532) veterans using VHA in 2002, accounting for age and medical/mental health conditions.Women had 11.8% more outpatient encounters, 25.9% fewer inpatient days, and 11.4% lower total cost than men; after adjusting for age and medical comorbidity, differences were less pronounced (1.3%, 10.9%, and 2.8%, respectively). Among the 30.8% of women and 24.4% of men with both medical and mental health conditions, women used outpatient services more heavily than men (31.0 vs. 27.3 annual encounters).VHA's efforts to build capacity for women veterans must account for their relatively high utilization of outpatient services, which is especially prominent in women who have both medical and mental health conditions. Meeting their needs may require delivery systems integrating medical and mental healthcare.

View details for DOI 10.1089/jwh.2006.0205

View details for Web of Science ID 000250506100063

View details for PubMedID 17937572

Abstract

Veterans Health Administration (VHA) databases are used extensively to study racial/ethnic disparities; however, these databases may not capture all care received by VHA patients.We examined the extent to which accounting for non-VHA care changed conclusions about racial/ethnic disparities for VHA patients with diabetes.Using a cross-sectional observational study, we analyzed a national sample of noninstitutionalized Hispanic (n = 5931), black (n = 24,670), and white (n = 149,222) VHA patients with diabetes who were at least 65 years of age for receipt of annual HbA1c testing, low-density lipoprotein (LDL) cholesterol testing, or eye examination from VHA and Medicare administrative files.In VHA alone data, adjusting for patient characteristics, Hispanic and black patients were as likely as white patients to receive HbA1c testing (odds ratio 1.06 [95% confidence interval 0.99-1.13] and 1.04 [1.00-1.07], respectively), and more likely to receive eye examinations (1.31 [1.24-1.38] and 1.33 [1.29-1.37], respectively). Hispanic patients were equally likely (1.01 [0.95-1.07]) and black patients were less likely (0.81 [0.79-0.84]) to receive LDL testing versus white patients. In VHA plus Medicare data, Hispanic and black patients were less likely than white patients to receive HbA1c (0.76 [0.71-0.82] and 0.83 [0.80-0.87], respectively) and LDL testing (0.84 [0.79-0.90] and 0.70 [0.68-0.72], respectively), and equally likely to receive eye examinations (0.91 [0.86-0.96]) and 0.98 [0.95-1.01]), respectively). Accounting for VHA facility had little effect on results.Restricting to VHA data masks racial/ethnic disparities in care of VHA patients. VHA researchers must be aware and supplement VHA data with other sources whenever possible.

View details for Web of Science ID 000237150000008

View details for PubMedID 16641662

Abstract

To examine gender differences in diabetes care process measures and intermediate outcomes among veteran clinic users.A retrospective cohort study using Veterans Health Administration (VHA) and Medicare files of VHA clinic users with diabetes. Diabetes care process measures were tests for hemoglobin A1c (HbA1c), low-density lipoprotein (LDL-C) values, and eye exams. Intermediate outcomes were HbA1c and LDL-C values below recommended thresholds. Chi-square tests and logistic regressions were used to assess gender differences.Study population included 3,225 women and 231,922 men veterans with diabetes, enrolled in Medicare fee-for-service and alive at the end of fiscal year 2000.Overall, there were no significant gender differences in HbA1c or LDL-C testing. However, women had higher rates in these process measures than men among the non-African American minorities. Women were more likely to have completed eye exams (odds ratio [OR]=1.11; 99% confidence interval [CI]=1.10, 1.23) but were less likely to have LDL-C under 130 mg/dL (OR=0.77; 99% CI=0.69, 0.87).Among VHA patients with diabetes, clinically significant gender inequality was not apparent in most of diabetes care measures. However, there was evidence of better care among nonwhite and non-African American women than their male counterparts. Further research on interaction of race and gender on diabetes care is needed. This includes evaluation of integrated VHA women's health programs as well as cultural issues. Lower LDL-C control among women suggests areas of unmet needs for women and opportunities for future targeted quality improvement interventions at system and provider levels.

View details for DOI 10.1111/j.1525-1497.2006.00374.x

View details for Web of Science ID 000235954500010

View details for PubMedID 16637945

Abstract

The expansion of women in the military is reshaping the veteran population, with women now constituting the fastest growing segment of eligible VA health care users. In recognition of the changing demographics and special health care needs of women, the VA Office of Research & Development recently sponsored the first national VA Women's Health Research Agenda-setting conference to map research priorities to the needs of women veterans and position VA as a national leader in Women's Health Research. This paper summarizes the process and outcomes of this effort, outlining VA's research priorities for biomedical, clinical, rehabilitation, and health services research.

View details for DOI 10.1111/j.1525-1497.2006.00381.x

View details for Web of Science ID 000235954500017

View details for PubMedID 16637953

Abstract

Male veterans receiving Veterans Health Administration (VA) care have worse health than men in the general population. Less is known about health status in women veteran VA patients, a rapidly growing population.To characterize health status of women (vs men) veteran VA patients across age cohorts, and assess gender differences in the effect of social support upon health status.Data came from the national 1999 Large Health Survey of Veteran Enrollees (response rate 63%) and included 28,048 women and 651,811 men who used VA in the prior 3 years.Dimensions of health status from validated Veterans Short Form-36 instrument; social support (married, living arrangement, have someone to take patient to the doctor).In each age stratum (18 to 44, 45 to 64, and > or =65 years), Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were clinically comparable by gender, except that for those aged > or =65, mean MCS was better for women than men (49.3 vs 45.9, P<.001). Patient gender had a clinically insignificant effect upon PCS and MCS after adjusting for age, race/ethnicity, and education. Women had lower levels of social support than men; in patients aged <65, being married or living with someone benefited MCS more in men than in women.Women veteran VA patients have as heavy a burden of physical and mental illness as do men in VA, and are expected to require comparable intensity of health care services. Their ill health occurs in the context of poor social support, and varies by age.

View details for DOI 10.1111/j.1525-1497.2006.00373.x

View details for Web of Science ID 000235954500009

View details for PubMedID 16637944

Abstract

Emerging evidence indicates that patients with mental health conditions (MHCs) may receive less intensive medical care. Diabetes serves as a useful condition in which to test for MHC-related disparities in care. We examined whether quality measures for diabetes care are worse for patients with or without MHCs.This national, cross-sectional study included 313 586 noninstitutionalized Veterans Health Administration patients with diabetes (identified from diagnostic codes and prescriptions) whose Veterans Health Administration facility transmitted laboratory data to a central database; 76 799 (25%) had MHCs (based on diagnostic codes for depressed mood, anxiety, psychosis, manic symptoms, substance use disorders, personality disorders, and other categories). National data from Veterans Health Administration records, Medicare claims, and a national survey were linked to characterize 1999 diabetes care.Failure to meet diabetes performance measures was more common in patients with MHCs: unadjusted odds ratio (95% confidence interval) was 1.24 (1.22-1.27) for no hemoglobin A(1c) testing, 1.25 (1.23-1.28) for no low-density lipoprotein cholesterol testing, 1.05 (1.03-1.07) for no eye examination, 1.32 (1.30-1.35) for poor glycemic control, and 1.17 (1.15-1.20) for poor lipemic control. Disparities persisted after case mix adjustment and were more pronounced with specific MHCs (psychotic, manic, substance use, and personality disorders). The percentage not meeting diabetes care standards increased with increasing number of MHCs.Patients with mental illness merit special attention in national diabetes quality improvement efforts.

View details for Web of Science ID 000233883800015

View details for PubMedID 16344421

Abstract

To determine whether patient gender influences physicians' management of late-life major depression in older and younger elderly patients.In 1996-2001, physician subjects viewed a professionally produced videotape vignette portraying an elderly patient meeting diagnostic criteria for major depression, then answered interviewer-administered questions about differential diagnosis and treatment. Patient gender and other characteristics were systematically varied in different versions of the videotape, but clinical content was held constant. This was a stratified random sample of 243 internists and family physicians with Veterans Health Administration (VA) or non-VA ambulatory care practices in the Northeastern United States. Outcomes were whether physicians followed a guideline-recommended management approach: treating with antidepressants or mental health referral or both and seeing the patient for follow-up within 2 weeks.Only 19% of physicians recommended treating depression (12% recommended antidepressants and 7% mental health referral), and 43% recommended follow-up within 2 weeks. Patient gender did not influence management recommendations in either younger old (67 year old) or older old (79 year old) patients (p > 0.12 for all comparisons).Gender disparities previously documented in the management of major conditions are not seen for the management of depression, a potentially stigmatized condition that does not require resource-intense interventions.

View details for Web of Science ID 000225396100007

View details for PubMedID 15671707

Abstract

Faith-based substance abuse rehabilitation programs provide residential treatment for many substance abusers. To determine key governing concepts of such programs, we conducted semi-structured interviews with sample of eleven clinical and administrative staff referred to us by program directors at six, Evangelical Christian, faith-based, residential rehabilitation programs representing two large, nationwide networks. Qualitative analysis using grounded theory methods examined how spirituality is incorporated into treatment and elicited key theories of addiction and recovery. Although containing comprehensive secular components, the core activities are strongly rooted in a Christian belief system that informs their understanding of addiction and recovery and drives the treatment format. These governing conceptions, that addiction stems from attempts to fill a spiritual void through substance use and recovery through salvation and a long-term relationship with God, provide an explicit, theory-driven model upon which they base their core treatment activities. Knowledge of these core concepts and practices should be helpful to clinicians in considering referrals to faith-based recovery programs.

View details for PubMedID 16150675

Abstract

Depression and posttraumatic stress disorder (PTSD) are important women's health issues. Depression is known to be associated with poor physical health; however, associations between physical health and PTSD, a common comorbidity of depression, have received less attention.To examine number of medical symptoms and physical health status in women with PTSD across age strata and benchmark them against those of women with depression alone or with neither depression nor PTSD.A random sample of Veterans Health Administration enrollees received a mailed survey in 1999-2000 (response rate, 63%). The 30 865 women respondents were categorized according to whether a health care provider had ever told them that they had PTSD, depression (without PTSD), or neither. Outcomes were self-reported medical conditions and physical health status measured with the Veterans SF-36 instrument, a version of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) modified for use in veteran populations.Across age strata, women with PTSD (n = 4348) had more medical conditions and worse physical health status (physical functioning, role limitations due to physical problems, bodily pain, and energy/vitality scales from the Veterans SF-36) than women with depression alone (n = 7580) or neither (n = 18 937). In age-adjusted analyses, the Physical Component Summary score was on average 3.4 points lower in women with depression alone and 6.3 points lower in women with PTSD than in women with neither (P<.001).Posttraumatic stress disorder is associated with a greater burden of medical illness than is seen with depression alone. The presence of PTSD may account for an important component of the excess medical morbidity and functional status limitations seen in women with depression.

View details for Web of Science ID 000222325400007

View details for PubMedID 15226164

Abstract

Medical providers often fail to treat depression. We examined whether treatment is more aggressive in a setting with accessible mental health resources, the Veterans Health Administration (VA). VA and non-VA primary care physicians and medical specialists viewed a videotape vignette portraying a patient meeting criteria for major depression and then answered interviewer-administered questions about management. We found that 24% of VA versus 15% of non-VA physicians would initiate guideline-recommended treatment (antidepressants or mental health referral, or both) (P = .09). Among those who identified depression as likely, 42% of VA versus 19% of non-VA physicians would treat (P = .002): 23% versus 3% recommended mental health referral (P < .001) and 21% versus 17% an antidepressant (P = .67). Although many patients with major depression may not receive guideline-recommended management, VA physicians do initiate mental health referral more often than do non-VA physicians. Access to mental health services may prove valuable in the campaign to increase physician adherence to depression clinical guidelines.

View details for Web of Science ID 000188437300005

View details for PubMedID 14977023

Abstract

Chronic diseases have been associated with decrements in health status, as measured by the Medical Outcomes Study's Short Form-36 (SF-36). Menstrual symptoms (including irregular menses, menorrhagia, dysmenorrhea and premenstrual symptoms) are common, but little is known about their impact on health status. We sought to determine the prevalence of menstrual symptoms and the degree to which these symptoms affect health status.This was a mailed survey including questions about sociodemographic characteristics, military experiences, current physical symptoms and medical conditions, mental health, health status (SF-36), and life experiences. The participants were a nationally representative, randomly selected sample of women veterans who had made at least one ambulatory visit to a Veterans Affairs facility between July 1, 1994 and June 30, 1995. The main outcome measures were eight domains of the SF-36 health status questionnaire.Among 3632 respondents (58.4% response rate), 1744 were menstruating women and formed the analytical sample for this study. Among these women (mean age 35.8), 67% reported one or more menstrual symptoms. Women with menstrual symptoms had significantly lower scores for all domains of the SF-36 (p < 0.01), except energy and vitality (p < 0.05), both before and after adjusting for sociodemographic, psychosocial, and comorbidity variables.Women veterans who report one or more menstrual symptoms have significantly lower health status compared with those reporting none. Clinicians providing care for women should be attuned to the potential impact of menstrual symptoms on the lives of their patients.

View details for Web of Science ID 000188532700011

View details for PubMedID 14670171

Abstract

The purpose of this article is to determine whether known cardiac risk factors are more prevalent among women veterans who report having sustained sexual assault while in the military. We surveyed a random sample of 3,632 women veterans using Veterans Administration (VA) ambulatory care nationally. Obesity, smoking, problem alcohol use, sedentary lifestyle, and hysterectomy before age 40 were found to be more common in women reporting a history of sexual assault while in the military than in women without such history. An association between myocardial infarction and prior sexual assault history may be mediated in part by known cardiac risk factors.

View details for PubMedID 12816405

Abstract

This study sought to determine whether blacks and whites with life-threatening cardiac events differ in likelihood of help seeking, types of help sought, or likelihood of reaching the hospital before death.Death certificates were used to identify all coronary heart disease-related deaths occurring in 1988-89 among 45- to 74-year-old, black and white, non-institutionalized residents of three contiguous inner-city districts in Boston, Massachusetts, USA. An informant was interviewed about the decedent's health status, access to care and pre-mortal help-seeking behaviors.Among the 232 decedents analyzed, there were no racial differences in the likelihood of help seeking. Among those who sought help, there were no racial differences in the likelihood of reaching the hospital. However, blacks were more likely than whites to engage in two specific help-seeking behaviors: calling the 911 emergency system, and trying to reach an emergency room.In an area where blacks and whites were similar with respect to socioeconomic status and access to care, race did not affect the likelihood of help seeking or the likelihood of succeeding in reaching the hospital before death.

View details for DOI 10.1080/1355785022000038560

View details for Web of Science ID 000179550200001

View details for PubMedID 12511195

Abstract

Recruitment of low-income and minority women to cancer-prevention trials requires a joint effort from specialists and primary care providers. We sought to assess primary care providers' attitudes toward participating in cancer-prevention trial recruitment.We conducted a focus group with seven Boston-based primary care providers serving low-income and minority women. Providers discussed knowledge, attitudes, and beliefs regarding their role in recruitment to prevention trials.A qualitative analysis of the focus group transcript revealed nine categories. Three categories related specifically to the primary care physician: 1) the dual role physicians play as advocates for both patient and research; 2) threats to maintaining the primary care relationship; and 3) general philosophy toward prevention. An additional six categories could be subdivided as they apply to the primary care physician, the patient, and the community: 4) trust/commitment; 5) benefits of the research; 6) access to the research; 7) knowledge and recall of the research; 8) influences of media coverage about the research; and 9) cultural sensitivity.Investigators conducting cancer-prevention trials must address the concerns of primary care physicians to optimize recruitment of subjects- especially low-income and minority women-into trials.

View details for Web of Science ID 000172158500008

View details for PubMedID 11730121

View details for Web of Science ID 000085225700005

Abstract

Among a national sample of 3,632 women VA outpatients, we determined self-reported prevalence of sexual assault experienced during military service and compared screening prevalence for current symptoms of depression and alcohol abuse between those who did and did not report this history. Data were obtained by mailed questionnaire. Military-related sexual assault was reported by 23%. Screening prevalence for symptoms of current depression was 3 times higher and for current alcohol abuse was 2 times higher among those who reported experiencing military-related sexual assault. Recent mental health treatment was reported by 50% of those who reported experiencing sexual assault during military service and screened positive for symptoms of depression, and by 40% of those who screened positive for symptoms of alcohol abuse.

View details for Web of Science ID 000084818700005

View details for PubMedID 10646179

Abstract

To profile differences in current physical symptoms and medical conditions among women users of Veterans Administration (VA) health services with and without a self-reported history of sexual assault sustained during military service, we conducted a cross-sectional analysis of a nationally representative, random sample of women veterans using VA outpatient services (n = 3632). A self-administered, mailed survey asked whether women had sustained sexual assault while in the military and requested information about a spectrum of physical symptoms and medical conditions. A history of sexual assault while in the military was reported by 23% of women VA users and was associated with current physical symptoms and medical conditions in every domain assessed. For example, women who reported sexual assault were more likely to indicate that they had a "heart attack" within the past year, even after adjusting for age, hypertension, diabetes, and smoking history (OR 2.3, 95% CI 1.3-4.0). Among women reporting a history of sexual assault while in the military, 26% endorsed > or = 12 of 24 symptoms/conditions, compared with 11% of women with no reported sexual assault while in the military (p < 0.001). Clinicians need to be attuned to the high frequency of sexual assault occurring while in the military reported by women VA users and its associated array of current physical symptoms and medical conditions. Clinicians should consider screening both younger and older patients for a sexual violence history, especially patients with multiple physical symptoms.

View details for Web of Science ID 000082361600016

View details for PubMedID 10495264

Abstract

This study compared the patient satisfaction of female and male veterans using Department of Veterans Affairs health care and examined the relationship between sociodemographic characteristics and satisfaction in men and women. Using data from the Department of Veterans Affairs Women's Health Project (N = 719) and the Veterans Health Study (N = 600), we examined women's and men's unadjusted and adjusted mean scores on three dimensions of satisfaction: location of health care facility, access to health care, and prescription services. Although the unadjusted results indicated that women were less satisfied with both location and access, there were no differences in satisfaction with prescription services. After adjusting for age and then for both age and a recent physician visit, women remained less satisfied with location but were more satisfied with prescription services; there were no differences on access ratings. In an exploratory analysis, we examined the relationships between sociodemographic, military experience, and health characteristics and satisfaction within each sample. Older age was the only characteristic consistently positively associated with each dimension of satisfaction among both women and men. General health perceptions were positively associated with all three dimensions of women's satisfaction but with only the location dimension for men. Although other characteristics were associated with satisfaction within each sample, these differed for women and men. The results suggest that although there were not consistent differences in mean satisfaction ratings by gender, the characteristics associated with satisfaction differed for men and women.

View details for Web of Science ID 000079664600011

View details for PubMedID 10226456

Abstract

We sought to determine how often non-English-speaking (NES) persons are excluded from medical research. DESIGN. Self-administered survey.A Medline search identified all original investigations on provider-patient relations published in major U.S. journals from 1989 through 1991, whose methodologies involved direct interaction between researcher and subject (N = 216). Each study's corresponding author was surveyed; 81% responded.Of the 172 respondents, 22% included NES persons; among these includers, 16% had not considered the issue during the study design process, and 32% thought including the NES had affected their study results. Among the 40% who excluded the NES (excluders), the most common reason was not having thought of the issue (51%), followed by translation issues and recruitment of bilingual staff. The remaining 35% (others) indicated that there were no NES persons in their study areas.NES persons are commonly excluded from provider-patient communication studies appearing in influential journals, potentially limiting the generalizability of study findings. Because they are often excluded through overnight, heightened awareness among researchers and granting institutions, along with the development of valid instruments in varied languages, may increase representation of non-English-speaking subjects in research.

View details for Web of Science ID A1996TR84200006

View details for PubMedID 8691285

View details for Web of Science ID A1995RJ91900001

View details for PubMedID 7734634

Abstract

To determine the prevalence of domestic violence among patients seen in three university-affiliated ambulatory care internal medicine clinics and to assess the personal characteristics of those patients affected by domestic violence.Survey using a self-administered, anonymous questionnaire.Three university-affiliated internal medicine clinics at the University of California Irvine Medical Center.We asked all patients on randomly selected days during the three-month study to participate. 453 (72%) of the 629 eligible English- and Spanish-speaking patients completed the questionnaire.28% of participants had experienced domestic violence at some time in their lives, and 14% were currently experiencing domestic violence. Logistic regression analysis showed that female gender, unmarried status, and poverty were important predictors of domestic violence. However, domestic violence occurred in all groups regardless of sex, ethnicity, age, or socioeconomic status.The study found an unexpectedly high prevalence of domestic violence in the three internal medicine clinics. Physicians should ask their patients routinely about domestic violence and, when domestic violence is present, should offer emotional support, information about social service agencies, and psychological care.

View details for Web of Science ID A1991FX36800008

View details for PubMedID 1890502